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[C54:1] A patient is on a ventilator in the ICU for severe pneumonia. The patient does not have decisional capacity, no oral or written preferences, no living will, and no durable power of attorney are on record. The patient’s condition continues to deteriorate. The patient’s older offspring wants to withdraw life-support, but the patient’s younger offspring disagrees. What should be done?
[C54:3] What should a practitioner do when surrogates at an equal level of authority disagree?
[C54:4] Since there are no oral or written preferences, no living will, and no durable power of attorney on record, medical decision-making authority now belongs to the surrogates. Both surrogates are legally and morally obliged to use substituted judgment, meaning that the patient’s reasonable goals, values, and priorities are used to make medical decisions, not the surrogate’s goals, values, and priorities. How substituted judgment decisions are to be conducted must be made clear to both surrogates, meaning that they are to be making decisions as if they were the autonomous patient. This means that the surrogates must clearly understand all aspects of informed consent: 1) the diagnosis, 2) treatment options, 3) goals or purposes of the treatment, 4) risks of harm and benefits of the various treatment options, including no treatment, 5) available alternatives including no treatment, and 6) have all their questions addressed. The practitioner must encourage discussion and consensus.
[C54:5] The practitioner has the professional obligation of beneficence (do good) and nonmaleficence (do no harm) to help the disagreeing surrogates to 1) discuss and come to a consensus as to what the patient would have wanted to have done under these circumstances using the patient’s reasonable goals, values, and priorities. If it is not possible to determine or come to an agreement on the patient’s reasonable goals, values, and priorities, then the surrogates will need to decide by 2) discussing and coming to a consensus as to what would promote the patient’s best interests.
[C54:6] Legal surrogates are mandated by law and moral principles to make decisions using substituted judgment as if they were the patient using the patient’s reasonable goals, values, and priorities. If the patient’s reasonable goals, values, and priorities are impossible to determine, then the surrogates need to decide using the patient’s best interests.
[C54:8] The recommendation is to encourage discussion and consensus on what would maximize the patient’s best interests using the patient’s reasonable goals, values, and priorities. If the surrogates cannot agree using substituted judgment, then it may be necessary to decide based simply on what a reasonable person would consider being in their best interests.
(Choice A) Since the surrogates disagree, it is up to the practitioner to decide.
(Choice B) Err on the side of life and keep providing life-support.
(Choice C) Encourage discussion and help the surrogates form a consensus.
(Choice D) Get a court order to appoint an independent proxy.
(Choice E) Get hospital risk management involved and have them assess the situation.